CHRONIC CARE INNOVATIONS
Registered Nursing
Services:
CCM and RPM
Programs
Chronic care management services and remote patient monitoring services consist of outreach by registered nurses once per calendar month, to patients with the required elements:
Chronic conditions expected to last at least 12 months, or until the death of the patient.
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Registered nursing services include:
New patient contact and enrollment with complete documentation.
Comprehensive care plan established with patient input and agreement, implemented, revised, and monitored
Communication to patient of chronic care management and remote patient management programs overview
Obtaining patient consents for both programs
Completion of patient education on co-insurance/copay
Communication of the ability to terminate from the program at any time
Communicate that only one practice can furnish CCM and RPM services during a calendar month
Ongoing monthly contact with enrolled patients including:
Monthly non-face-to-face chronic care coordination and remote patient monitoring encounters & document
Development, review and update of individual patient care plans with the patient input and agreement
Working with patient on each item of care plan to promote optimal health
Monitoring remotely patient’s medications, vital signs, blood sugars as needed and appropriate to each patient
Coordination of patient care: transitions, appointments, community resources..etc.
Providing patient education on chronic conditions, medications, healthy lifestyle activities, and optimal vital signs and labs.
Providing a clinical resource for patients with chronic conditions.
